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August 3, 2011

Emerging HIV Epidemics In Men Who Have Sex With Men In The Middle East And North Africa

by Sam Savage

HIV epidemics are emerging among men who have sex with men (a term that encompasses gay, non-gay identified homosexual men, transgendered, and bisexual men) in several countries in the Middle East and North Africa. Importantly, the high level of risky sexual behavior practiced by many men who have sex with men in these countries indicates that they could become the pivotal risk group for HIV sexual transmission in this region.

These are among the key findings of a detailed and comprehensive review and data synthesis (the first of its kind in this region) led by Laith Abu-Raddad and Ghina Mumtaz from the Infectious Disease Epidemiology Group at the Weill Cornell Medical College in Doha, Qatar. The study, published in this week's PLoS Medicine, stresses the urgent need for countries in the Middle East and North Africa to expand HIV surveillance and access to HIV testing, prevention, and treatment services for men who have sex with men, to limit the size of the HIV epidemic, and to prevent the chains of HIV transmission from reaching other population groups.

The authors identified relevant published studies and collected and analyzed data from country-level and international organization reports and databases, governmental and nongovernmental organization publications, and various other institutional documents to find that, contrary to widely held perceptions, there is considerable and increasing epidemiological evidence on HIV and risk behavior among men who have sex with men in this region.

The prevalence of HIV infection among men who have sex with men was low in several countries but high in others, with evidence for concentrated epidemics (HIV prevalence greater than 5%) in several countries such as Egypt, Sudan, and Tunisia. In one setting in Pakistan, HIV prevalence reached up to 28%. Moreover, by 2008, transmission of HIV via the route of anal sex among men was responsible for more than a quarter of notified cases of HIV in several countries in the region. Not all countries, however, conducted studies to assess the level of HIV infection among their men who have sex with men population, thereby limiting the understanding of the full scale of the problem in the region.

Roughly 2-3% of males were found to engage in anal sex with other males, a rate that is comparable to that in other regions. These males were typically involved in several types of HIV-related high risk behavior. For example, they had between 4 and 14 sexual partners in the past six months and their rates of consistent condom use were generally below 25%. In addition, between 20% and 75.5% of men who have sex with men exchanged sex for money, and these men commonly had several female sexual partners.

The authors stressed that given the spectre of expanding epidemics among men who have sex with men, and a narrowing window of opportunity to prevent further epidemics, policy makers in the Middle East and North Africa should address this growing health challenge from a public health perspective. Few countries in the region have already developed creative means of dealing with this public health issue through empowerment of non-governmental organizations that deliver services to this highly hidden population. These programs need to be expanded in scale and initiated in the rest of the countries to achieve the desired coverage for a substantial impact.